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Key Points The origin of a posttraumatic wrist joint stiffness can be either extra-articular, intraarticular, or both. Surgical arthrolysis is a viable option that can be performed via open or arthroscopic surgery. A poor articular surface may be responsible for failure or recurrence of painful stiffness after arthrolysis Arthroscopy of the DRUJ can be challenging. Panel 1: Case Scenario Case 1: A 24-year-old male manual worker…
Key Points Before embarking for salvage procedures, conservative treatment and corrective osteotomy should have been considered. If these measures are inapplicable or fail, partial or extensive wrist denervation should be considered. Partial or total wrist (TW) arthrodesis or arthroplasty are the next options to be considered, arthroplasties being more suited for the low-demand/elderly patients. If the midcarpal joint is intact, a radioscapholunate (RSL) arthrodesis is another…
Key Points Salvage procedures of distal radioulnar joint (DRUJ) arthritis after distal radius fractures (DRFs) can be divided in resection arthroplasties and implant arthroplasties. Corrective osteotomy, ulnar shortening, ligament—reinsertion or reconstruction should be considered before reconstruction of the joint. Specific indications for the different reconstructive procedures after DRFs have not been established, and the scientific evidence for any treatment is weak. Decision on what operative treatment…
Key Points The triangular fibrocartilage complex (TFCC) and its proximal component, the radioulnar ligaments, constitute the primary intrinsic stabilizer of the distal radioulnar joint (DRUJ). TFCC injuries are frequently associated (in up to 78% of cases) with distal radius fractures, although the vast majority heals without long-term sequalae. Chronic lesions of the proximal component of the TFCC can cause pain and DRUJ instability. The volar and…
Key Points The incidence of tendon ruptures after distal radius fracture is rare, currently 1%–3%, and generally occur within the first year after surgery. The extensor pollicis longus (EPL) or flexor pollicis longus (FPL) are most often involved tendons, and rupture of flexor or extensor tendons to the fingers were also reported. The key to prevent flexor tendon rupture is to properly position the plate, and…
Key Points While the cause of nonunion is often multifactorial, both injury (open fracture, severe comminution, soft tissue interposition) and patient (diabetes, smoking, obesity, substance abuse, malnutrition, peripheral vascular disease, social situation) factors play a role. Treatment is based on the history of previous surgical attempts, the status of the radiocarpal joint, and the status of the distal radioulnar joint. Commonly utilized methods include orthogonal plating,…
Key Points Malunion is the most common complication following a distal radius fracture. Restoration of anatomy is a key factor in obtaining good functional outcome, but this can be technically challenging. Next to radiographs and CT-scans, three-dimensional (3D) visualization and printed bone models can further improve understanding of the malunion pattern. The use of three-dimensional (3D) computer planning and the production of patient-specific instruments allow accurate…
Key Points Intraarticular malunion following distal radius fracture (DRF) leads to radiographic arthritis, but the effect on functional outcome is not well understood. Evidence evaluating operative and nonoperative treatment of intraarticular malunion is of low quality. Some small, retrospective case series suggest osteotomy will improve outcome after intraarticular DRF malunion. Surgery is challenging with high complication rate and need for re-operation. There is insufficient evidence to…
Key Points The relationship between malunion and functional outcome following distal radius fracture (DRF) is not well understood. Some patients tolerate malunion well, whereas others have poor functional outcome. Evidence evaluating operative and nonoperative treatment of extraarticular malunion is largely of low quality. Distal radius osteotomy is likely to improve symptoms in carefully selected patients with a symptomatic malunion following DRF. Complication rate and need for…
Key Points The diagnosis of a malunited distal radius fracture (DRF) must take into account both clinical symptoms and radiographic findings Standard radiographs of both the affected and contralateral wrist are usually sufficient to diagnose distal radius malunions, but CT scans can provide additional information for complex deformities Panel 1: Case Scenario A 72-year-old, right hand dominant, retired male presents to your office with chronic left…
Key Points Distal radius fractures (DRFs) are common in patients’ aged 50 and older, typically resulting from a low energy mechanism such as a fall from standing height. DRFs in this population offer an opportunity to identify patients with a high likelihood of osteoporosis or osteopenia and represent a potential to intervene and prevent future fragility fractures. Recognition of at risk adults using tools such as…
Key Points Epidemiology: Fractures of the distal radius are the most common upper extremity fracture sustained in the elderly population. The incidence of these fractures is expected to increase in the future with increasing cost to the healthcare system. Nonsurgical Treatment: Conservative treatment has been shown to correlate with radiographic malunion, cosmetic deformity, and diminished grip strength. However, a number of studies have demonstrated that despite…
Key Points Accept only minor fracture displacement in diaphyseal forearm fractures because the remodeling capacity is low and even mild malunion can result in impaired forearm rotation. Diaphyseal forearm fractures that are stable after reduction can be treated nonoperatively with an above-elbow cast followed by a below-elbow cast. Unstable fractures need additional fixation. Re-fractures occur frequently and give a higher change of impaired forearm rotation. Panel…
Key Points Treatment of pediatric distal radius fractures (DRFs) is challenging because of possible involvement of the physis and the remodeling capacity by growth. Young children with a fracture close to the most active distal physis angulated in the sagittal plane have the highest remodeling capacity. Predictors for secondary fracture displacement in cast are initial complete displacement and inadequate reduction. Cast index is not a predictor…
Key Points Diagnosis of complex regional pain syndrome (CRPS) is challenging and remains a hot topic of debate as despite decades of research, the etiology remains entirely unclear. Recent randomized controlled trials have questioned the role of vitamin C as a prophylactic treatment of CRPS in patients with distal radius fractures (DRFs). The risk of CRPS following DRFs is independent of the fixation technique. However, tight…
Key Points Current evidences show no significant difference of clinical outcomes between patients treated with versus without additional physiotherapeutic intervention, but high-quality studies are lacking. Patient education and exercise (so-called home exercise program) seems sufficient after distal radius fracture (DRF) based on current evidence, suggesting that there is no need to prescribe a routine supervised physiotherapy session for all patients. The subgroup who would obtain significant…
Key Points Restoration of the main radiographic distal radial parameters has long been a focus of treatment in closed versus open management of distal radial fractures (DRFs). Commonly used radiographic predictors for assessing adequate anatomic restoration include radial inclination, sagittal tilt (dorsal and volar), radial shortening, as well as intraarticular incongruity. In review of the literature, radial height and articular incongruity have the most significant effect…
Key Points The development of palmar locking plate fixation for surgical treatment for distal radius fracture (DRF) provides successful outcome. However, persistent ulnar-sided wrist pain (USWP) after healed DRF is often encountered. USWP is common after DRF and can improve for a year or more, so patience is warranted. The main causes of persistent USWP after healed DRF are malunion of the distal radius, triangular fibrocartilage…